Record Traumatic Stress

Thank you for taking the time to complete this form, we know it is not easy to do but we also know that the collection of this information will help make change for the entire profession. It is our hope that someday, this type of data will not exist.

If you are feeling suicidal, PLEASE CONTACT A PROFESSIONAL IMMEDIATELY.

Instructions

Please note that all fields marked with an asterisk (*) are required to provide relevant and accurate reporting. These fields are not confidential in that they will be used for reporting purposes. For instance, it will be reported the number of males and females who report suffering PTSD, the number of states with the highest PTSD rates, etc.
Items without asterisks are not required. If provided, this information is strictly confidential and will not be disclosed without prior consent.
If you wish to report the name of the officer you may, this will help with the vetting process but will be kept confidential. At no time will this piece of information be shared without your permission. This is not required for reporting purposes.
Contact information for the person reporting is requested so that we may ensure the information is accurate and reliable. We will not contact you unless absolutely necessary.

Please Note

Important - This is not a medical/ pyschological site. No medical advice is dispensed, this is merely for data collection. The information is not advice, and should not be treated as such. You must not rely on the information on this website as an alternative to medical advice from your doctor or other professional healthcare provider.

If you have any specific questions about any medical matter you should consult your doctor or other professional healthcare provider. If you think you may be suffering from any medical condition you should seek immediate medical attention. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.

Any personal information collected herein will be kept strictly confidential, you department will not have access to this information.

If you are feeling suicidal, PLEASE CONTACT A PROFESSIONAL IMMEDIATELY.

Name of Officer

Gender*

Male

Female

Current Age*

Years of Service*

Are you

Active Duty

Retired

Medically Separated

Marital Status*

Single

Married

Divorced

Separated

Military Veteran*

Yes

No

Department*

Sheriff

Local Police

Constable

State Police / Highway Patrol

Fire

EMS

Corrections

Dispatcher

City

State*

Country*

Age at time of initial traumatic incident*

This can be the date that you were initially diagnosed, the age that you experienced the trauma or the age you realized you had post-traumatic stress.

Have you been formally diagnosed with post-traumatic stress?

Yes - Diagnosed by a Doctor

No - No Medical Diagnosis

Self Diagnosed

Have you received any of the following after a critical incident?

Departmental Debriefing

Peer Debriefing

Referral to Therapist

Never had a debriefing

Have you experienced any of these symptoms?

Nightmares

Depression

Insomnia

Feeling anxious, jittery or irritated

Recurrent memories of the traumtic event/ flashbacks

Feeling emotionally numb

Unable to relate to others

Self-destructive behavior

Loss of interest in things you previously enjoyed

Suicidal thoughts

Have you ever attemped suicide?

Yes

No

Unknown

Have you sought help?*

Yes

No

Unknown

Do you know if post-traumatic stress is covered by your insurance/ workman's compensation?*

Yes, it is

No, it's not

I don't know

Do you know where to find help in your area?*

Yes

No

If you have not sought help, why not?

Check all that apply

Stigma

Fear of reprisal at work

Don't know where to get help

Insurance doesn't cover it

Don't want to talk about it

I should be able to deal with it myself

Embarassed/ Ashamed

Don't want anyone to know

Is there anything else you would like us to know?

You may detail the experience that caused the post-traumatic stress, symptoms or other pertinent information that will help us understand stress in law enforcement. This can be a single incident or an accumulation of smaller incidents that by themselves did not cause a stress response but taken together result in the response.

Your contact information

Name

FirstLast

Email

Phone

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